For more information about

Tennis Innovators, please visit

www.tennisinnovators.com.

CAUSE A RACQUET TINY TOT TENNIS ACADEMY SUMMER 2012

MORE INFORMATION: Tamara Heisler, Director of Healthy Lifestyles

212-912-2670 | theisler@ymcanyc.org

The Tiny Tot Tennis Academy is a program designed to help young children discover

the joy of tennis. It is a great way to keep young ones fit and introduce them to a

lifelong sport. Instructors for this program are part of the Tennis Innovators

program whose mission is to deliver a passion and commitment for tennis and

continuously develop and conduct the highest level programs for adults and children.

DATES: August 27 - 31, 2012

DAY/TIME: M - F

9:00 - 12:00 Noon

AGES: 4 - 5 yrs.

LOCATION: 4th Floor Gymnasium

FEES: $300/Week

WEST SIDE Y 5 West 63rd Street; New York, NY 10023 212-912-2600 / ymcanyc.org/westside

Need financial assistance? JUST ASK!

SPECIALTY SPORTS CAMP REGISTRATION FORM 2012

Camper’s Name____________________________________________________________________ Campers Age________

(First) (Middle) (Last)

Date of Birth_______/_______/_______ Sex_______ T-Shirt Size :( child) S M L XL (adult) S M L XL

Address_____________________________________________ Apt#_____ City___________________, NY or ____, Zip.________

Parents/Guardians:

Parent Name 1:___________________________________ Parent 2:____________________________________________

Business #: (______)________________________________ Business #: (_______)________________________________

Mobile Phone: (_______)____________________________ Mobile Phone:(_______)_____________________________

Email Address: ____________________________________ Email Address: _____________________________________

Authorized Pick Up and Emergency Contact Information At dismissal and/or incase of an emergency the following people are authorized to pick up my child:

Parent 1 YES NO Parent 2: YES NO

At least two additional names are required:

1. Relation: Phone #:

2. Relation: Phone #:

3. Relation: Phone #:

Please select the camp week you wish to attend and if extended care is needed:

Please turn over and complete the reverse side

Dismissal Options Choose one:

I_______________will be picking my child up from Westside YMCA between 12:00PM. (Tennis Camp Only)

(Initial)

I_______________ will be picking my child up from Westside YMCA between 1:00PM. (Basketball Camp Only)

(Initial)

I_______________ will be picking up my child at between (5:30 – 6:00pm) ___________PM. (Extended day hours Basketball only)

(Initial)

I_______________ give permission for my child (10 +) to walk home from the program unattended at ____________PM. (Initial)

Session Dates Summer Camp weeks

(Please check box) $/week

Extended Care (Please check box)

Total Price

Tennis Camp 6/11 – 6/15

06/11 – 06/15

$ 300 Not Available $

Tennis Camp 6/18 – 6/22

06/18 – 06/22 $ 300 Not Available $

Basketball Camp 8/13 – 8/17

08/13 - 08/17 $ 300 PM $150/WK

$

Basketball Camp 8/20 – 8/24

08/20 - 08/24 $ 300 PM $ 150/WK

$

Sub Total $

Membership Fee if applicable $ +

_____ % Discount (type:_______________) $ -

Payments and Fees Information Fees & Discounts (discounts cannot be combined):

Membership Fees - Ages 5 -11, $216 per year and age 12 - 17, $336 per year.

Payment is due in fill upon registration.

Siblings receive a 10% discount when both children are registered for the same number of sessions.

Early Bird discount of 10% for participants who registered by June 9th for Tennis and by August 1st for

Basketball Camp and payment in full by the start of the program.

Form of payment accepted credit card, debit card or cash. No checks accepted for camp payments.

Payment Deadlines:

Tennis Camp Week 1 & 2 full payment due by Friday, June 9th, 2012.

Basketball Camp full payment due by Friday, August 1st, 2012.

Credit Card Information I authorize West Side YMCA to charge my credit card account on Friday, June 9th, 2012 for (Tennis Camp

Week 1 & 2) in the amount of $_____________and on Friday, August 1st, 2012 for (Week 1 & 2 ) in the amount of

$__________ in fulfillment of my child’s summer day camp payment obligation.

Master Card Discover Card Holder’s Signature________________________________________

Credit Card # __________________________________________ Expiration Date: ______________ Security Code: ___________

Refund and Credit Policy Camp fees are non-refundable unless the YMCA cancels a camp and Credits will be issued at the Directors discretion.

The YMCA reserves the right to cancel a camp if it does not meet enrollment requirements.

A $50 per week is nonrefundable & nontransferable.

To apply for a credit you must submit a credit request application stating the reason the child cannot attend before the

scheduled session. Please make sure you include any doctor’s notes and/or travel documents to support your case.

There will be no refunds or credits granted after June 22nd, 2012.

Refunds take 6-8 weeks to process.

Standard Release Form I, the undersigned give permission for my child to participate in all summer camp activities for the days he/she attends. I

understand that no refund or credit will be given for missed days under any circumstances. I understand that I must have a

completed medical form on file BEFORE the first day of the summer camp program. I also hereby give authority to the YMCA

staff to obtain necessary emergency medical treatment for my child with the understanding that the family will be notified as

soon as possible. Also, in consideration of the goodwill, public service, and community aid provided by the YMCA of Greater

New York, which I support and from which I have received benefit, I hereby grant permission to the YMCA to use my child’s

name, to take and publish photographs, videotapes or motion pictures of him/her which include his/her voice, in any media for

any legitimate purpose. I release all rights to such photographs, videotapes, motion pictures and recordings. I acknowledge

that the YMCA will be the sole owner of all rights arising out of their use for all purposes. I understand that I shall receive no

compensation from their use from any source whatsoever.

Parent or Guardian’s Signature___________________________________ Date__________________

If at any point the information on the Registration form needs to be changed, you must submit ALL changes in writing.

2012 Specialty Sports Camp West Side YMCA

Childs Name Age

Shirt Size

Office Use Only

Application Received By Date __/__/__

Place a Passport

Size Photo of your

Child Here The Photo must have

been taken within 6

months from the start of camp.

Place a Passport

Size Photo of your

Child Here The Photo must have

been taken within 6

months from the start

of camp.